Huntington Internal Medicine Group
5170 US RT 60 East
Huntington, WV 25705
Phone 304-528-4600
Fax 304-528-4652
AUTHORIZATION FOR USE OR RELEASE OF YOUR HEALTH INFORMATION
Name (print): _________________________________________________________________
Address: ____________________________________________________________________
Date of Birth: ________________________ Social Security Number: ____________________
I authorize HIMG to use or disclose my health information as described below.
Who: Name and address of person or organization receiving the information:
What: Specific description of information (including date[s] if appropriate):
Sensitive information: Please read carefully. By law you must sign below or we cannot release
the following information:
HIV/AIDS test/treatment
Sign here to release:
Sexually transmitted disease
Sign here to release:
Drug/alcohol problem
Sign here to release:
Mental health information
Sign here to release:
Genetic testing
Sign here to release:
Sexual assault
Sign here to release:
Abortion
Sign here to release:
Why: Specific description of the purpose of the use or disclosure:
I understand that this authorization is voluntary. If I do not sign this form, my healthcare from
HIMG and the payment for this healthcare will not be affected.
I understand that once my information is released, it may no longer be protected by Federal
privacy regulations.
I understand that I may see and copy the information described on this form if I ask for it, and I
will get a copy of this form after I sign it.
I understand that this authorization will expire:
I understand that after I have signed this form, I may change my mind and cancel (revoke) this
authorization at any time by notifying HIMG’s Privacy Officer in writing. But if I do, it won’t have
any effect on actions HIMG took before the revocation was received.
Signature of patient or patient’s representative
(Do not sign until the information above is filled in completely.)
Printed name if patient’s representative:
Relationship to patient:
Huntington Internal Medicine Group * 5170 US RT 60 East * Huntington, WV 25705
Phone 304-528-4600 * Fax 304-528-4652
Date
Instructions
Patient name and demographics are essential to identifying the correct health record.
Who—Fill in the name of the person, department, or organization to receive the requested
information, and their address.
What—Fill in specific information about what is to be released. For example, “all information
related to the episode of care on January 10, 2001.”
Sensitive information—HIMG is not allowed to release this information without a
signature on each relevant line.
Why— Fill in the specific purpose for the use/disclosure.
Expiration—Fill in the date on which the authorization expires or the number of days from
signing (e.g., “30 days from date of signing”)
Huntington Internal Medicine Group * 5170 US RT 60 East * Huntington, WV 25705
Phone 304-528-4600 * Fax 304-528-4652